http://dx.doi.org1550-7289/r 20(http://creativeco

*CorrespondTaksim German

E-mail: dokt

Surgery for Obesity and Related Diseases 11 (2015) e5–e7

Online case report

Laparoscopic diverted resleeve with ileal transposition for failedlaparoscopic sleeve gastrectomy: a case report

Alper Çelik, M.D.a,b,*, Surendra Ugale, M.D.c, Hasan Ofluoğlu, M.D.aaDepartment of General Surgery, Taksim German Hospital Metabolic Surgery Clinic, Istanbul, Turkey

bDepartment of General Surgery, Yeniyuzyil University Faculty of Medicine, Istanbul, TurkeycBariatric and Metabolic Surgery Clinic, Kirloskar Hospital, Hyderabad, India

Received September 2, 2014; accepted September 16, 2014

Abstract Laparoscopic sleeve gastrectomy (LSG) recently gained popularity for the treatment of obesity and

/10.1015 Ammo

ence:Hosporalpe

related co-morbidities. With the increasing number of bariatric operations, the requirement for redoor revision bariatric surgery seems to be increasing. In the present case, a 50-year-old female patientwith failed LSG who underwent laparoscopic resleeve, duodenal diversion, and ileal transposition ispresented. Her metabolic and biochemical parameters were found to be improved significantly after18 months. To the best of our knowledge, this is the first report of a case treated with this method inthe literature. (Surg Obes Relat Dis 2015;11:e5–e7.) r 2015 American Society for Metabolic andBariatric Surgery. This is an open access article under the CC BY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/3.0/).

Keywords: Obesity; Diabetes mellitus; Treatment; Surgery; Laparoscopic sleeve gastrectomy; Revision; Resleeve; Duodenal

diversion; Ileal transposition1

Obesity has an increasing prevalence worldwide, andsurgical treatment offers the highest success rates withsustainable results [1,2]. Laparoscopic sleeve gastrectomy(LSG) recently gained popularity for the treatment ofobesity and related co-morbidities [3,4]. Technical feasibil-ity and simplicity plays an important role in the trendtoward LSG. On the other hand, LSG possesses somelimitations. Even though the procedure itself is not a purelyrestrictive operation, long-term data suggests that weightregain and recurrence of co-morbidities are not rare [5,6].With the increasing number of bariatric operations, therequirement for redo or revision bariatric surgery seems tobe increasing. The 2 main reasons for revision are compli-cations or unexpected outcomes related to initial surgeryand recurrence of the initially remitted co-morbidities linkedwith metabolic syndrome. Revision surgery can eliminateboth problems. Bariatric surgeons should choose an appro-priate option for revision, in patients with a failed sleeve or

16/j.soard.2014.09.010merican Society for Metabolic and Bariatric Surgery. Thisns.org/licenses/by-nc-nd/3.0/).

Alper Celik, M.D., Department of General Surgery,ital Metabolic Surgery Clinic, Istanbul, Turkey.r@hotmail.com

those who do not attain their treatment goals with a LSGalone. In this case report, we present a patient with failedLSG who underwent laparoscopic resleeve, duodenaldiversion, and ileal transposition. To the best of ourknowledge, this is the first report of a case treated withthis method in the literature.

Case presentation and management

A 50-year-old female patient was admitted to our clinicwith weight regain and worsening of glycemic control andkidney function tests 4 years after an initial LSG operation.She had a previous history of type 2 diabetes (T2 DM) of 22years duration and hypertension. She had undergone theLSG procedure 4 years ago at another tertiary care center.Her initial body mass index (BMI) was 37.1 kg/m2 beforesurgery, which was reduced to 32.7 kg/m2 2 years aftersurgery. She started to regain weight within the past 2 years.At the time of admission to our clinic, her BMI was foundto be 35.2 kg/m2. Her medication included premix insulin24/18 IU (twice daily), acetylsalicylic acid (100 mg),

is an open access article under the CC BY-NC-ND license

A. Çelik et al. / Surgery for Obesity and Related Diseases 11 (2015) e5–e7e6

acarbose (50 mg twice daily), iron supplement (ferro glycolsulphate, 225 mg daily), and diuretics (furosemide, 40 mgonce daily). She was also receiving potassium loweringmedication (spironolactone, 25 mg once daily). Her averageblood pressure was 135/90 mm Hg, HbA1c 7.7%, totalcholesterol 202 mg/dL, very low-density lipoprotein 32 mg/dL, and triglyceride 181 mg/dL. Her creatinine was 1.6 mg/dL, urea was 58 mg/dL, creatinine clearance was 51 (70–110 mg/mL/min), and parathormone was 313.2 pg/mL. Herliver function tests were within normal limits, and abdomi-nal ultrasound showed the presence of stones within thegallbladder. She was mildly anemic (hemoglobin [Hb]: 11g/dL, hematocrit [Htc]: 33.5%). Upper gastrointestinalendoscopy revealed a dilated stomach with a remnantfundus and erosive gastritis; bilateral retinal examinationshowed early diabetic retinopathy.We decided to perform a laparoscopic resleeve with

duodenal diversion, ileal interposition, and cholecystec-tomy. Briefly, the operation started with a trimming of theremnant fundus and antrum followed by duodenal trans-ection. The sleeved stomach was transferred to the lowerabdomen through a retro-colic opening in the transversemesocolon. A 170-cm segment of ileum was prepared withpreservation of the last 30 cm of terminal ileum. Theproximal and distal ends of ileum were anastomosed to eachother. The proximal end of the ileal segment was anasto-mosed to the duodenal part of the sleeve, and the distal endwas anastomosed to the jejunum at 50 cm from the ligamentof Treitz (Fig. 1). The patient had an uncomplicatedpostoperative course and was discharged from the hospital6 days after surgery. At 18 months after surgery, the patient

Fig. 1. Illustration of resleeve operation with duodenal diversion, ilealinterposition, and cholecystectomy. 1-2: Resleeve, 3: Infracolic transfer of thesleeved stomach, 4: Ileal Transposition and final configuration of the operation.

had lost 31 kg and BMI dropped down to 23.6 kg/m2. HerHbA1c was 6.2%, total cholesterol was 154.6 mg/dL, andhigh-density lipoprotein was 66.62 mg/dL without medi-cation. She achieved normal blood pressure with ramipril 5mg/d, and kidney function tests normalized. Parathormonelevels dropped down to 95 pg/mL. Her vitamin B12, folate,and vitamin D levels, as well as bone mineral densitometry,were all normal. Anemia initially worsened with Hb andHtc levels reaching 7.22 g/dL and 27.1%, respectively.After iron replacement therapy, her Hb and Htc levels roseup to 9.9 g/dL and 33%. With 18 months follow up, theonly problem to be pronounced is that she still needs ironreplacement treatment.

Discussion

Failure after LSG is not rare, and revisional optionsshould be sought for patients who fail to achieve treatmenttargets after LSG. The possible options reported includeconversion to gastric bypass, minigastric bypass, or duode-nal switch. This patient had an initial BMI of 37.1 kg/m2,which came down to 32.7 and rose to 35.2 kg/m2 4 yearsafter the LSG. She was not severely obese and had anHbA1c of 7.7%. The main reason for surgery was thealteration in her kidney function tests.We did not prefer duodenal switch in this patient because

of the possibility of significant malabsorption and worsen-ing of the hematological parameters that were alreadydeteriorated. Another option was a gastric bypass, eitherin the form of Roux-en-Y gastric bypass (RYGB) or mini-gastric bypass (MGB); however, because of the bypass ofduodenum and proximal 200 cm of the jejunum, MGBwould have brought an additional risk of significant irondeficiency, which the patient already suffered from. RYGBwas not preferred for 2 reasons: (1) the patient presentedwith mild weight regain (2.5 kg/m2 increase in BMI) and(2) her main concern was worsening of kidney function, notweight gain. In a patient with mild weight regain andmoderate kidney failure, it is difficult to identify whetherthis is due to fat deposition or a volume (liquid) overload.Therefore, the expectations from the surgery were toaccomplish a remission of metabolic syndrome-related co-morbidities and to obtain improvement in the kidneyfunctions, as well as to achieve these results withoutcausing significant malabsorption.The metabolic outcomes of bariatric surgery are depend-

ent on the combination of weight control and alterations ingut hormones. Bariatric surgery currently constitutes theonly therapy available for obesity that results in long-termsustained weight loss with reduction in mortality andmorbidity [7]. Beneficial metabolic effects can be observedin addition to long-term weight loss. Ileal transposition mayact by mimicking the distal gut peptides response to an oralnutrient load, via peptide YY, glucagon-like peptide-1, andoxyntomodulin, and can be the surgery of choice in selected

Laparoscopic Diverted Resleeve with Ileal Transposition / Surgery for Obesity and Related Diseases 11 (2015) e5–e7 e7

patients [8–10]. In other words, there is an importantmodulatory neuroendocrine aspect of the surgical interven-tion performed.Diverted sleeve gastrectomy with ileal transposition

(DSIT) operation has been shown to be effective for thetreatment of type 2 Diabetes and other related co-morbidities. It both improves kidney function tests andoffers the possibility to minimize the risk of significantmalabsorption [11–13]. Another possible factor for ourselection of surgical method is our clinical tendency towardDSIT. Our clinic is a dedicated Bariatric Surgery Center ofExcellence, and we have been performing DSIT since 2011.Since then, 4500 patients have been operated with DSIT.In parallel to the previous data in literature [11–13], wehave also observed marked improvements in the kidneyfunction tests in patients with diabetic nephropathy andsome other microvascular complications such as retinop-athy. Hopefully, a good metabolic control can contribute tothe regression of these microvascular events. On the otherhand, we believe that control of hypertension and weight-loss-related decrease in liquid and osmotic load furthersupports the regression of nephropathy.In our patient, DSIT provided remission in all compo-

nents of metabolic syndrome, leading to marked weightreduction and normalization of kidney functions. It isdifficult to determine whether resleeve only or resleevewith ileal transposition as a combination surgery had themain effect on the final outcome. Nonetheless, it should benoted that ileal transposition is performed in combinationwith sleeve gastrectomy from the beginning. The firstreason for this circumstance is that ileal transpositionwithout a sleeve will lead to gastric dilation and intractablenausea. Second, the diverted sleeve needs to be broughtthrough a transverse mesocolic opening to the lower abdo-men to perform a safe and tension-free duodeno-ilealanastomosis; technically, this would be more challengingwithout a sleeve. Third, to obtain better metabolic results, itis essential to utilize the beneficial effects of sleevegastrectomy with respect to reduced ghrelin levels andhigher ileal stimuli because of increased gastric emptying[11–13].We are aware of the fact that a single case report has a

limited value from extrapolation of the message to applica-tion to larger populations. Moreover, we have a clinicalpreference for performing this type of surgery. Hence,authors of the present article routinely perform Ileal Trans-position in selected patients with type 2 diabetes. Bariatricand Metabolic surgeons should keep ileal transposition asan effective alternative to gastric bypass or duodenal switchin patients with failed sleeve gastrectomy. Further clinicaltrials on larger series are warranted for clarification of theindications, the pros, and the cons of the procedure.

Conclusion

Ileal transposition with or without resleeve can be a safe,reliable, and effective option for LSG failures with accept-able nutritional side effects. Although long-term data is stillpending, beneficial results with acceptable complicationrates can be obtained with well-trained and dedicated teams.The technical difficulty and complexity of this operationcan be overcome by well-organized education models.

Disclosures

The authors have no commercial associations that mightbe a conflict of interest in relation to this article.

References

[1] Bermudez DM, Pories WJ. New technologies for treating obesity.Minerva Endocrinol 2013;38:165–72.

[2] Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versusintensive medical therapy in obese patients with diabetes. N Eng JMed 2012;366:1567–85.

[3] Braghetto I, Korn O, Valladares H, et al. Laparoscopic sleevegastrectomy: surgical technique, indications and clinical results. ObesSurg 2007;17:1442–50.

[4] Felberbauer FX, Langer F, Shakeri-Manesch S, et al. Laparoscopicsleeve gastrectomy as an isolated bariatric procedure: intermediate-term results from a large series in three Austrian centers. Obes Surg2008;18:814–8.

[5] Weiner RA, Weiner S, Pomhoff I, Jacobi C, Makarewicz W, WeigandG. Laparoscopic sleeve gastrectomy—influence of sleeve size andresected gastric volume. Obes Surg 2007;17:1297–305.

[6] Langer FB, Bohdjalian A, Felberbauer FX, et al. Does gastric dilationlimit the success of sleeve gastrectomy as a sole operation for morbidobesity? Obes Surg 2006;16:166–71.

[7] Sjöström L, Narbro K, Sjöström C, et al. Effects of bariatric surgeryon mortality in Swedish obese subjects. N Engl J Med 2007;357:741–52.

[8] Hansen CF, Vassiliadis E, Vrang N, et al. The effect of ilealinterposition surgery on enteroendocrine cell numbers in the UCDavis type 2 diabetes mellitus rat. Regul Pept 2014;189 C:31–9.

[9] Cummings BP, Graham JL, Stanhope KL, Chouinard ML, Havel PJ.Maternal ileal interposition surgery confers metabolic improvementsto offspring independent of effects on maternal body weight in UCD-T2 DM rats. Obes Surg 2013;23:2042–9.

[10] Troke RC, Tan TM, Bloom SR. The future role of gut hormones inthe treatment of obesity. Ther Adv Chronic Dis 2014;5:4–14.

[11] DePaula AL, Stival AR, DePaula CC, Halpern A, Vencio S. Surgicaltreatment of type 2 diabetes in patients with BMI below 35: mid-termoutcomes of the laparoscopic ileal interposition associated with asleeve gastrectomy in 202 consecutive cases. J Gastrointest Surg2012;16:967–76.

[12] De Paula AL, Stival AR, Halpern A, et al. Improvement in insulinsensitivity and β-cell function following ileal interposition with sleevegastrectomy in type 2 diabetic patients: potential mechanisms. JGastrointest Surg 2011;15:1344–53.

[13] DePaula AL, Macedo AL, Rassi N, et al. Laparoscopic treatment oftype 2 diabetes mellitus for patients with a body mass index less than35. Surg Endosc 2008;22:706–16.